What should a male patient with dysuria (painful urination) and penile soreness for 2 days do?

Management of Dysuria and Penile Soreness in a Male Patient

This patient requires immediate testing for gonorrhea and chlamydia, followed by empiric antibiotic treatment covering both organisms while awaiting results, with azithromycin 1 g orally as a single dose PLUS ceftriaxone for gonorrhea coverage. 1

Immediate Diagnostic Approach

The presence of burning urination (dysuria) and penile soreness for 2 days indicates urethritis until proven otherwise. 1 You must document that urethritis is actually present before initiating treatment by confirming at least one of the following: 1

• Mucopurulent or purulent urethral discharge 1
• Gram stain showing ≥5 white blood cells per oil immersion field 1
• Positive leukocyte esterase test on first-void urine 2
• ≥10 white blood cells per high-power field in urine sediment 2

If diagnostic tools are unavailable in your setting, treat empirically for both gonorrhea and chlamydia immediately. 1

Primary Pathogens and Testing

The two bacterial pathogens of proven clinical importance are Neisseria gonorrhoeae and Chlamydia trachomatis. 1 Testing for both is strongly recommended because: 1

• Both infections are reportable to health departments 1
• A specific diagnosis improves compliance and partner notification 1
• Nucleic acid amplification tests (NAATs) on first-void urine are highly sensitive and can detect both organisms 1

Chlamydia causes 23-55% of nongonococcal urethritis cases, with lower prevalence in older men. 1 Other organisms like Mycoplasma genitalium and Ureaplasma urealyticum account for up to one-third of cases, but specific testing for these is not routinely indicated. 1

Empiric Treatment Regimen

Start treatment as soon as possible after diagnosis to prevent complications including epididymitis and transmission to partners. 1 The medication should ideally be dispensed on-site with the first dose directly observed to maximize compliance. 1

Recommended First-Line Treatment:

• Azithromycin 1 g orally as a single dose 1
  • OR Doxycycline 100 mg orally twice daily for 7 days 1
  • PLUS coverage for gonorrhea (ceftriaxone or cefixime) 2

Azithromycin has the advantage of single-dose therapy with improved compliance and is more effective against Mycoplasma genitalium infections. 1 However, doxycycline is equally effective for chlamydial urethritis. 1

Alternative Regimens (if first-line unavailable):

• Erythromycin base 500 mg orally four times daily for 7 days 1
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1
• Levofloxacin 500 mg orally once daily for 7 days 1
• Ofloxacin 300 mg orally twice daily for 7 days 1

Critical Patient Instructions

Instruct the patient to abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen AND until symptoms have completely resolved. 1 To minimize reinfection risk, abstain until all sex partners are treated. 1

Partner Management

All sex partners within the preceding 60 days must be referred for evaluation, testing, and empiric treatment with a regimen effective against chlamydia, regardless of whether a specific etiology is identified in the index patient. 1 Expedited partner treatment (giving the patient prescriptions for partners) is an acceptable alternative approach endorsed by the CDC. 2

Additional Testing Required

Test for other sexually transmitted infections including syphilis and HIV in all patients diagnosed with a new STD. 1

Follow-Up Protocol

Instruct the patient to return if symptoms persist or recur after completing therapy. 1 However, symptoms alone without objective signs of urethral inflammation are NOT sufficient basis for retreatment. 1

Test-of-cure (repeat testing 3-4 weeks after treatment) is NOT recommended for patients who received recommended regimens and whose symptoms resolved. 1 However, repeat testing at 3-6 months IS recommended because men with documented chlamydial or gonococcal infections have high reinfection rates within 6 months. 1

Common Pitfalls to Avoid

• Do not treat based on symptoms alone without documenting objective signs of urethritis (discharge, pyuria, or WBCs on Gram stain). 1
• Do not assume compliance or partner treatment—reinfection rates are high, necessitating repeat testing at 3-6 months. 1
• If symptoms persist beyond 3 months, consider chronic prostatitis/chronic pelvic pain syndrome rather than persistent urethritis. 1
• For persistent urethritis after treatment, consider testing for Trichomonas vaginalis using urethral swab, first-void urine, or semen culture/NAAT, as this organism can cause urethritis in men. 1